Local Anesthesia for Dental Professionals - Clinical action of specific la
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Local Anesthesia for Dental Professionals - Clinical action of specific la
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Local Anesthesia for Dental Professionals - Clinical action of specific la
- 1. Of Specific Local Anesthetics Based on Text- Local Anesthesia for Dental Professionals 1st ed. Dr. StanleyMalamed 2nd ed. Bassett, DiMarco, Naughton Local Anesthesia for Dental Professionals
- 2. ο Individual response to LA ο Bell shaped curve β normal responder ο Accuracy of deposit of LA - injection target ο Tissue pH ο Anatomic Variation ο Type of injection (block or infiltration)
- 3. ο Normoresponders ο Average patient no problem ο Hyperresponder ο LA more effective longer and possibly quicker ο Hyporesponders ο LA less effective, shorter and slow onset
- 4. ο IANB ο Technique sensitive ο Anatomic variation ο Infiltration ο Easier to place solution ο Dissipation of solution helps
- 5. ο Influences onset and duration ο Inflammation, infection, and pain decreases depth and duration ο Increased vascularity of site ο Low pH more cations ο and slower dissociation into axon
- 6. ο Height of mandibular foramen ο Width of ramus ο Bifid inferior alveolar nerve ο Accessory nerves ο Sensory innervation by lingual and mylohyoid nerves
- 7. ο Type of injection influences the duration ο Nerve Block ο Longer duration ο Infiltration ο Shorter duration ο Less than recommended volumes will decrease onset and duration ο Larger doses do not increase duration
- 8. ο Related as mg/kg or mg/lb ο Normoresponders ο Maximum dose based on body weight ο Produces a LA blood level below usual threshold for an overdose or toxic reaction ο Response is usually mild β tremor or drowsiness ο Hyporesoponders ο May not experience adverse Rxn until LA level is considerably above the normal overdose
- 9. ο Hyperresponder ο May demonstrate clinical signs of LA ο overdose At blood levels significantly lower than normal ο Always minimize the amount of LA ο Smallest clinical effective dose
- 10. 88 mg / 36 mg carpule = 2.4
- 11. ο Risk groups ο DECREASE DRUG DOSAGE ο Geriatric ο Medically compromised and organ functions diminished ο Pediatric ο Not fully developed and light weight is easy to overdose ο May be a hyperresponder ο Hepatic disease ο Do not metabolize drug normally ο Half life of drug increased
- 13. ο If met or exceeded ο does NOT guarantee an overdose ο Hyper responders ο may OD at doses lower than MRD
- 14. ο Lidocaine 2% ο MRD is 3.2 mg/lb ο or 500 mg. maximum ο 100 lb. patient ο MRD = 100 lb x 3.2 mg/lb= 320 mg ο Cartridge 1.8 ml x 20 mg/ml = 36 mg/cartridge ο #cartridges under MRD ο 320 mg MRD divided by 36 mg/ cartridge ο 8.8 cartridges for 100 lb patient
- 15. ο Articaine 4% ο MRD is 3.2 mg / lb ο Dose = 1.7 ml x 40 mg/ml = 68 mg / cartridge ο 90 lb patient ο 90 lb x 3.2 mg/lb = 288 mg MRD ο # cartridges under MRD ο 288 mg MRD divided by 68 mg/cartridge ο 4.2 cartridges for 90 lb patient
- 16. ο Mepivicaine 3% ο MRD is 3.0 mg/lb ο Dose / vial = 1.8ml x 30 mg/ml = 54 mg/cargridge ο 20 kg patient (20 kg x 2.2 lbs/kg = 44 lbs) ο 44 lbs x 30 mg/lb = 132 mg MRD ο # cartridges under MRD ο 132 mg divided by 54 mg/cartridge ο 2.4 cartridges for 44 lb patient 1 kg = 2.2 lbs
- 17. ο Calculate MRD for each LA ο The lowest MRD is the safe threshold ο Both LA added together ο must be under the lowest MRD
- 18. ο Mepivicaine 2% w/levonordefrin 1:20,000 ο MRD is 3mg/lb ο Mepivicaine 2% = 36 mg / carpule ο 45 kg patient - 45 x 2.2 = 99 lbs ο MRD is 99 lbs x 3 mg / lb = 297 mg. ο 2 cartridges = 72 mg ο Articaine 4% = 68 mg / carpule ο MRD is 3.2 mg/lb ο 99 lb patient - 99 x 3.2 = 317 mg ο LOWEST MRD = MEPIVICAINE = 297 MG ο 297 mg - 72 mg mepivicaine = 225 mg of MRD remaining ο 225 mg divided by 68 mg/carpule = 3 carpules may be used 45 kg x 2.2 lb/kg = 99 lbs
- 19. ο Hydrolyzed by blood plasma pseudocholinesterase ο Metabolites ο PABA β para-aminobenzoic acid β allergic rxns ο Diethylaminoethanol ο Excreted in kidneys ο Vasodilator action on blood vessels
- 20. ο Lidocaine ο Articaine (hybrid) ο Mepivicaine ο Bupivicaine
- 21. Amide ο Lidocaine ο Articaine ο Mepivicaine ο Prilocaine ο Bupivicaine ο Dibucaine ο Etidocaine ο Cocaine ο Benzocaine ο Tetracaine Esther (Topical use)
- 22. ο Amide ο Metabolized in liver by microsomal oxidases & amidases ο Pregnancy category B ο Excretion by kidneys ο MRD ο 3.2 mg / lb ο 7 mg / kg
- 23. ο Allergy to amide LA is nearly nonexistent ο Safe when used properly ο Available in 2% with ο 1:50,000 epi ο 1:100,000 epi ο Vasoconstrictor ο Decreases blood flow due to ο alpha adrenergic constriction (epinephrine = vasoconstrict) ο Distribution is slowed due to slower absorption into bv ο Increases depth and duration of LA ο Reduces blood level of LA
- 24. ο Vasoconstrictor ο Decreases blood flow due to alpha adrenergic action to cause constriction ο Distribution is slowed due to slower absorption into BV ο Increases depth and duration of LA ο Reduces blood level of LA ο MRD for vasoconstrictor β epinephrine driven ο ASA 3 β 4o micrograms / appt ο Epi 1:100,000 = .01 mg / ml x 1.8 ml = .018 mg / carpule ο .04 mg divided by .018 mg/ carpule = 2 cartridges
- 25. ο Amide ο Metabolized in liver ο by microsomal oxidases ο Excretion by kidneys ο Slight vasodilation ο Pregnancy category C ο Duration : 20-40 minutes ο Concentrations ο 3% without constrictor ο 2% with vasoconstrictor
- 27. ο Mepivicaine plain ο Frequently used in pediatrics and geriatrics ο 3% without vasoconstrictor ο Recommended for patients ο with vasoconstrictor contraindications
- 28. ο Provides depth and duration ο Due to vasoconstrictor levonordefrin ο Allergy is rare to non-existant ο Overdose signs ο Stimulation followed by depression ο Drowsiness to loss of consciousness ο Possible to have absence of stimulation
- 30. ο Amide ο Secondary amine ο Metabolism by hepatic amidases into ο Orthotoluidine ο can induce methemoglobinemia ο N - propylalanine ο Excretion β kidneys ο Pregnancy category B ο Greater vasodilation than mepivicaine ο and less vasodilation than xylocaine
- 31. ο Consistently reduces blood oxygen carrying capacity ο Can cause cyanosis ο Limit total dose to 600 mg ο Plasma levels of prilocaine decrease faster than lidocaine ο Thus is considered less toxic ο Maximum Dose - 4 mg/lb ο To maximum of 600 mg.
- 32. ο Can provide anesthesia equal duration to ο Lidocaine or mepivocaine with epinephrine ο Relatively contraindicated in patients with ο Methemoglobinemia ο Hemoglobinopathies (sickle cell anemia) ο Congestive heart failure (CHF) ο Respiratory failure ο Acetaminophen or phenacetin that elevate methemoglobin
- 33. ο Eutectic mixture of LA ο Lidocaine ο Prilocaine ο Penetrates skin β ectodermis ο In uncharged base form
- 34. ο Hybrid molecule β both esther and amide ο Metabolism ο plasma esterase ο and hepatic microsomal enzymes ο Excretion β kidneys ο Vasodilation equal to lidocaine ο Pregnancy class C ο Maximum dose ο 7 mg/kg (3.2 mg/lb)
- 37. ο Only amide ο to possess thiophene ring making it lipid soluble ο Has a Sulphur atom ο Contraindication - If patient allergic to sulfur ο IV doses can cause methemoglobinemia ο Not recommended in age 4 or younger & geriatrics ο Contraindicated with amide allergy ο Preservative sodium metabisulfite ο Contraindication - persons with sulfite sensitivity ο Patients with allergic type asthma
- 38. ο Amide ο Related to mepivicaine ο Butyl group replaces methyl ο 400% more potent than lidocaine (4x) ο 400% less toxic than lidocaine and mepivicaine ο Metabolized in liver by amidases ο Excretion by kidneys 16% unchanged ο Vasodilating ο greater than lidocaine, prilocaine and mepivicaine
- 40. ο Pregnancy Class C ο Maximum recommended dose 90 mg ο No dose based on body weight ο .5% concentration ο 1:200,000 epi ο Indications ο Lengthy dental appointments needing 90 minutes LA ο Management of post op pain ο DIMINISHES NEED FOR OPOIDS
- 41. ο Not recommended ο Hepatic disease ο Amide allergy ο Younger patients ο Those who could injure themselves by biting their lip ο Mentally disabled, young, geriatric
- 42. ο Length of time - duration ο Post treatment pain control ο .5% bupivicaine 8-12 hours soft tissue anesthesia ο Risk for young and old whose cognitive ability is limited ο Bite their lip, cheek, or tongue ο 3% mepivicaine may be better ο Hemostasis ο Vasoconstrictor 1:50,000 or 1:100,000 epi ο 1:200,000 concentrations are not effective for hemostasis
- 43. ο Absolute ο Not administered ever ο Life threatening risk unacceptable ο Medical contraindication ο True documented allergy ο Relative ο Preferable to avoid LA in question ο The risk of adverse reaction is increased ο Seek an alternative LA ο If acceptable alternative is not available may be used with caution
- 44. ο Amides are preferred to esters whenever possible ο Due to safety margin ο Fewer allergic reactions ο Decreased risk of methemoglobinemia
- 45. ο βAtraumaticβ administration of injections ο Topical typically will not diffuse thru epidermis ο Will penetrate mucous membrane or abraided skin
- 46. ο Higher concentration (more base molecule) ο May be 7.5% and up to 15% concentration ο Promotes diffusion thru mucous membrane ο Increases toxicity ο Vasodilating properties and absorption can be rapid ο Dose is important ο Blood levels can rise rapidly to IV levels of admin. ο Typically active 2-3 mm deep only ο Allows atraumatic needle penetration
- 47. ο Insoluble in water ο Soluble in ο alcohol, propylene glycol and polyethylene glocol ο Vehicles for surface application
- 48. ο Esther ο Poor solubility in water ο Overdose or systemic reaction is unknown ο Localized allergic reaction can occur ο Remains at site of application longer ο prolonged duration ο Inhibits antibacterial action of sulfonamides
- 49. ο Ketone Derivative ο Without esther or amide linkage ο May be used in patients allergic to common LA ο Cross sensitization with other LA doesnβt occur ο Potency equal to cocaine ο Onset slow - 10 minutes ο Duration long β 1 hour ο Toxicity is extremely low due to water insolubility ο .5 % used in dentistry
- 50. ο Lidocaine 5% base ο Spray, ointment, patch and solution ο Poorly water soluble- used on open wound / skin ο Lidocaine HCl ο water soluble β in topical solution 20 0r 40 mg/ml ο Penetrates tissue more effectively than base form ο Greater absorption and risk of toxicity ο Maximum recommended dose 200 mg
- 52. ο Long duration esther LA ο Highly soluble in water ο Topically is 5-8 x more potent than cocaine ο Onset slow and duration about 45 minutes ο Metabolized in plasma by estherases ο Maximum dose topically is 20 mg ο Greater potential for systemic toxicity
- 53. ο A sterile gauze wipe should be used to prepare tissues prior to injection ο Helps reduce post injection infections
- 54. ο Minimal quantity of topical on applicator tip ο Applied directly to site ο Allow 1 minute ο Studies state 10 β 15 seconds is adequate ο but patients feel rushed ο 2-3 minutes gives profound tissue topical anesthesia
- 55. ο Benzocaine β ester - is not absorbed systemically ο Local reactions only = angioneurotic edema of lips ο Lidocaine - amide β topical anesthesia ο Greater risk due to systemic absorption ο EMLA effective for intraoral but not designed for this Ester allergy Angioneurotic edema
- 56. ο Eutectic Mixture of Local Anesthetics ο Lidocaine 2.5% + Prilocaine 2.5% ο Surface anesthesia for intact skin ο Contraindication ο Methemoglobinemia ο Amide sensitivity ο Younger than 12 months with treatment by methemoglobin inducing agents ο Not recommended for use on mucous membranes
- 59. ο More rapid onset ο Greater depth of penetration ο Higher concentration of base molecules ο Because of prilocaine ο Risk of methemoglobinemia
- 60. ο Both are amides, eutectic mixture @ 2.5% ο Onset in 1 minute ο Duration 14 β 13 minutes ο Designed for intrapocket use ο Liquid at room temperature ο thickens to gel subgingivally ο Syringe with blunt tip applicator ο Low systemic toxicity ο 20-40% of drug systemic
- 61. ο Unmetered β NOT recommended ο Metered dose β may be used ο If a continuous spray is used ο Rapid absorption ο May reach OD levels quickly ο Spray nozzle must be changed